Note: Descriptions are shown in the official language in which they were submitted.
CA 02508591 2005-05-27
System and Method having a Hierarchical Model with Override Capability
for Generating a Flexible Insurance Plan
Field of the Invention
The present invention relates to claim adjudication of insurance plans.
Background of the Invention
The adjudication of a claim is one of the primary functions of an adjudication
engine,
which is done according to a predefined insurance plan. At the heart of the
adjudication process
is the execution of business rules to determine the eligibility of a claim and
its parts (with respect
to the plan), and if the parts are eligible, what amount should be paid.
However, there currently
exists insurance plan schemes that do not allow for flexibility and
individuality of insurance plan
design and maintenance. For example, two people with the same general set of
plan attributes
but with a few slightly different maximums and frequencies would have to have
individual plans
constructed for each of them, involving separate people and benefit models
with associated rules.
This process of designing two separate plans is undesirable, as there would be
a fair amount of
duplication in the resultant individual benefit and people models and
associated rules. There is a
further disadvantage with current insurance plan models for defining conflict
resolution, since
the execution order of complicated sets of rules is typically rigid in
assignment.
It is an object of the present invention to provide a system and method for
defining a
flexible insurance plan for the purpose of adjudication to obviate or
otherwise mitigate at least
some of the above presented disadvantages.
Summary of the Invention
Typically two people with the same general set of plan attributes but with a
few slightly
different maximums and frequencies would have to have individual plans
constructed for each of
them, involving separate people and benefit models with associated rules. This
process of
designing two separate plans is undesirable, as there would be a fair amount
of duplication in the
resultant individual benefit and people models and associated rules. There is
a further
disadvantage with current insurance plan models for defining conflict
resolution, since the
execution order of complicated sets of rules is typically rigid in assignment.
On the contrary, the
CA 02508591 2005-05-27
present invention provides a system and method for implementing an insurance
plan to
coordinate an adjudication of a submitted claim corresponding to the plan. The
plan includes a
people model and a benefit model, such as hierarchical trees combined by a
plurality of policies.
The system and method comprise assigning a first predefined inheritance of
global attributes to
coupled elements of the people tree and assigning a second predefined
inheritance of global
attributes to coupled elements of the benefits tree. The system and method
also assigning a local
administration rule for at least one local attribute of the trees, the
assignment between a selected
people element of the people tree and a selected benefit element of the
benefits tree. The local
administration rule overrides the corresponding global attributes of the
selected elements, such
that resolution of the global attributes with the local attributes for the
selected elements provides
a rule set for adjudication of the submitted claim.
According to the present invention there is provided a method for implementing
an
insurance plan to coordinate an adjudication of a submitted claim
corresponding to the plan, the
plan including a people model and a benefit model combined by a plurality of
policies, the
method comprising the steps of: assigning a first predefined inheritance of
global attributes to
coupled elements of the people model; assigning a second predefined
inheritance of global
attributes to coupled elements of the benefits model; and assigning a local
rule for at least one
local attribute, the assignment between a selected people element of the
people model and a
selected benefit element of the benefits model, the local rule for overriding
the corresponding
global attributes of the selected elements; wherein resolution of the global
attributes with the
local attributes for the selected elements provides a rule set for
adjudication of the submitted
claim.
According to a further aspect of the present invention there is provided a
system for
implementing an insurance plan to coordinate an adjudication of a submitted
claim
corresponding to the plan, the plan including a people model and a benefit
model combined by a
plurality of policies, the system comprising: the people model having a first
predefined
inheritance of global attributes to coupled elements of the model; the
benefits model having a
second predefined inheritance of global attributes to coupled elements of the
model; and a local
rule for assigning to at least one local attribute, the assignment between a
selected people
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CA 02508591 2005-05-27
element of the people model and a selected benefit element of the benefits
model, the local rule
for overriding the corresponding global attributes of the selected elements;
wherein resolution of
the global attributes with the local attributes for the selected elements
provides a rule set for
adjudication of the submitted claim.
According to a still further aspect the present invention there is provided a
computer program product for implementing an insurance plan to coordinate an
adjudication of a
submitted claim corresponding to the plan, the plan including a people model
and a benefit
model combined by a plurality of policies, the computer program product
comprising: a
computer readable medium; a people model module stored on the medium having a
first
predefined inheritance of global attributes to coupled elements of the people
model; a benefits
model module stored on the medium having a second predefined inheritance of
global attributes
to coupled elements of the benefits model; and a local rule module stored on
the medium for
assigning to at least one local attribute, the assignment between a selected
people element of the
people model and a selected benefit element of the benefits model, the local
rule for overnding
the corresponding global attributes of the selected elements; wherein
resolution of the global
attributes with the local attributes for the selected elements provides a rule
set for adjudication of
the submitted claim.
Brief Description of the Drawings
A better understanding of these and other embodiments of the present invention
can be
obtained with reference to the following drawings and detailed description of
the preferred
embodiments, in which:
Figure 1 is an overview of a claims processing environment;
Figure 2 is an example configuration of a claim of Figure 1;
Figure 3 represents functional structure of an adjudication engine of the
environment of Figure 1;
Figure 4 is a functional view of a plan corresponding to the claims of Figure
1;
Figure5 is a structured policy model of the plan of Figure 4;
Figure 6 is an example construction of an instantiated policy of the plan of
Figure 4;
Figure 7 is an example of a structured people model of Figure 1;
Figure 8 is an example of a structured provider model of Figure 1;
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CA 02508591 2005-05-27
Figure 9 is an example of a structured benefits model of Figure 1;
Figure 10 is an example plan showing the linked models of Figures 7 and 9;
Figure 11 is an example of rule resolution between products in the model of
Figure 9; and
Figure 12 is an example of rule resolution between people in the model of
Figure 7.
It is noted that similar references are used in different figures to denote
similar
components.
Detailed Description of the Preferred Embodiment
Referring to Figure 1, a claims processing system 10 interacts over a network
11; with people 12
receiving insurance applicable products and services, with providers 14 (e.g.
dentists, optometrists,
physicians, physiotherapists, etc...) that are providing the products and
services to the people 12, and
with payors 16 (e.g. insurance companies) that are responsible for paying for
the services and products
according to an insurance plan 408 (see Figure 4). The network 11 can be such
as but not limited to the
Internet and/or a private network. The providers 14 and the people 12 can use
a claim submission
system 18 to submit claims 20 to the processing system 10 for adjudication.
The claims submission
system 18 is a generalized actor that can represent all systems that are able
to submit claims 20 to the
processing system 10. For example, the claim submission system 18 can include
such as but not limited
to a provider EDI System (not shown), a payor claims submission & management
system (not shown),
and a member web claims submission system (not shown).
Referring again to Figure 1, the processing system 10 has a claims management
module 22 for
receiving the claims 20 and processing them in a suitable form for subsequent
adjudication by an
adjudication engine 24. Once adjudicated, the adjudication engine 24 directs a
decision 26 of the
adjudicated claim (including such as but not limited to payment details,
entitlement details, claims
history, and other explanation of benefits EOB) to a reporting module 28 and
to a payment engine 30.
The payment engine coordinates details of payment for the adjudicated claim 20
to the payor 16, for
subsequent settlement of accounts with the people 12 and providers 14. The
reporting module 28 can
provide detailed reports on explanation of benefits, claim history and payment
to the payor 16, providers
14, and people 12, as desired.
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CA 02508591 2005-05-27
Referring to Figure 2, there can be multiple claim 20 types that define the
types of
transaction entering the Adjudication Engine 24 through the management system
22 (see Figure
1). The possible claim 20 types are such as but not limited to new claim, void
claim, adjust claim,
new estimate, void estimate, and adjust estimate. The claim 20 may contain
multiple line items
202 of multiple benefit types (e.g. dental, health, vision, drug, etc...) for
multiple patients 12
from multiple providers 14 (with one payor 16 for one member such as a company
with multiple
insured people 12 or an individual person 12 - see Figure 1). The Claim
Management System 22
assigns a unique identifier to each claim 20, such as a Claim ID. A subclaim
200 represents the
collection of all line items 202 from the claim 20 for the same benefit type.
The Claim
Management System 22 assigns a unique identifier to each subclaim 200, such as
a Subclaim ID.
Each of the Line Items 202 represent each element from the claim 20 related to
one patient 12,
one service/product, and one provider 14. The Claim Management System 22
assigns a unique
identifier to each line item 202, such as a Line Item ID. It is recognized
that other claim 20
configurations than described above can be used in the processing system 10
(see Figure 1 ), if
desired.
Referring to Figures 2 and 3, the Adjudication Engine 24 is responsible for
executing
policies for subclaim 200 processing (and the processing of the subclaim's
line items 202). The
engine 24 executes subclaim and line item policies 402 (see Figure 4) in order
to determine the
payable amount for a set of the line items 202. The results of the
adjudication process are passed
as the decision 26 back to the Claim Management System 22 so that claim level
rules may be
applied (i.e. reassemble the individual subclaims 200 back into their original
claim 20). The
Adjudication Engine 24 is responsible for executing rules at the subclaim 200
and line item 202
level in order to determine the eligibility of the subclaim 200 or line item
202, and to determine
the payable amount if the subclaim 200 or line item 202 is eligible. The
Adjudication Engine 24
can be responsible for processing the following types of transactions:
~ New Claims;
~ Claim Adjustments;
~ Void Claims;
~ New Estimates;
~ Estimate Adjustments; and
~ Void Adjustments.
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CA 02508591 2005-05-27
Referring again to Figure 3, the Adjudication Engine can have 4 major
components that
are responsible for processing the subclaims 200 (see Figure 2) on different
steps of the
adjudication process. A Subclaim Processing Manager 300 is responsible for
accepting
subclaims 200 from the claim management system 22. It is also responsible for
decomposing
subclaims 200 into line items 202 and executing all required Policies 402 to
prepare subclaims
200 for adjudication. A Line Item Processing Manager 302 is responsible for
preparing the line
items 202 for adjudication that can include such as but not limited to:
loading Line Item Policies,
converting procedure code; and applying overndes to resolve conflicts (further
described below).
A Rules Engine 304 is responsible for processing all Policies 402 associated
with the line items
202. A Post Adjudication Manager 306 is responsible for processing
adjudication results and
creating a result set represented by the decision 26 (see Figure 1 ). It is
recognized that all four
components of Adjudication Engine 24 participate in Adjudication Engine
processing flow and
can be configurable by a processing flow profile module 308 and different
types of Policies. In
general, the basic flow managed by the module 308 can include such as but not
limited to:
identify the claimed service/product, date of service, payor, group,
membership, patient and
provider from the line item 202 context; obtain all policies and agreements
that are associated to
the entities identified in the line item 202 context; read and assemble the
policies and agreements
obtained; resolve conflicting policies 402 and agreements 404 (see Figure 4)
through overrides;
and place the resolved agreement 404 and policies 402 into the line item 202
and/or subclaim
200 context.
Referring to Figure 4, the plan 408 (in context of which the claim 20 and
subclaims 200
can be applied) is an assembly of people 12 and potential productslbenefits
400 for insurance
purposes. The people 12 and the products/benefits 400 are each represented as
hierarchical trees
(see Figures 7 and 9) that are interconnected by a series of plan or
administration rules 401. The
plan rules 401 includes plan attributes such as policies/rules 402 and
associated terms and
conditions 406, further described below, which are incorporated by the
agreement 404. The
agreement 404 can represent the link between people/provider 12, benefit lists
400, policies 402,
and their terms & conditions 406 (parameters and effective period).
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CA 02508591 2005-05-27
Referring again to Figure 4, the plan 408 can be generated by a plan setup and
maintenance system 409 having a user interface 416 interacting with the module
410. The
interface 416 is coupled to a processor 414, to interact with a user (not
shown) to construct the
plan 408. The user interface 416 can include one or more user input devices
such as but not
limited to a QWERTY keyboard, a keypad, a trackwheel, a stylus, a mouse, a
microphone and
the user output device such as an LCD screen display 412 and/or a speaker. If
the screen 412 is
touch sensitive, then the display 412 can also be used as the user input
device as controlled by
the processor 414. The user interface 416 is employed by the user to
coordinate creation and
maintenance of the plan 408 with the associated models 700,800,900 (see
Figures 7,8,9) and
administration rules 401.
Further, it is recognized that the user interface 414 can include a computer
readable
storage medium 420 coupled to the processor 416 for providing instructions to
the processor 416
and/or to load/update features of the plan 408 contained in the memory 418,
for ultimate
deployment on the claim processing system 10 (see Figure 1) to assist the
adjudication engine 24
in adjudication of claims 20 associated with the plan 408. The computer
readable medium 420
can include hardware and/or software such as, by way of example only, magnetic
disks,
magnetic tape, optically readable medium such as CD/DVD ROMS, and memory
cards. In each
case, the computer readable medium 420 may take the form of a small disk,
floppy diskette,
cassette, hard disk drive, solid state memory card, or RAM provided in the
memory 418. It
should be noted that the above listed example computer readable mediums 420
can be used
either alone or in combination.
Referring to Figure S, an example of the number of policies 402 that can be
included in
the plan 408 (Figure 4) is shown. It should be noted that each policy 402
contains a series of
rules 506 for implementing the corresponding policy 402 under the auspices of
the plan 408 (see
Figure 4). The individual policies 402 are organized in a policy model or tree
500 that provides
for global priority of their execution order (of their respective contained
rules 506) during
processing of the claims 20 and corresponding subclaims 200. For example,
location of the
policies 402 in the policy tree S00 dictates their order of execution, such as
from the top level
512 to the bottom level 514, and from left to right in each level. For
example, under the global
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CA 02508591 2005-05-27
priority an Adjudication Policy 502 would execute after a Switching Policy
504, and a Standard
Dental Practice Policy 508 would execute after an Eligibility Policy S 10. It
is noted that SDP
represents standard dental procedure.
However, a further feature of the plan 408 (see Figure 4) is that local
priorities can be set
for each of the policies 402 in the tree 500 irrespective of the policy 402
location. This setting of
individual policy 402 priority overrides the overall execution order
represented by global priority
of the tree 500. This setting of local policy priority for individual policies
402 of the tree 500
could be performed for example by a plan administrator module 410 (see Figure
4) during initial
set-up and maintenance of the plan 408. It is recognized that not every policy
402 of the model
500 automatically has a local priority setting. For example, the global
inheritance scheme of the
model 500 can assign priorities to policies 402 except in the case of
conflicts, as further
described below, in which local priority settings for affected policies 402
are used by the
administrator during setup and/or maintenance of the plan 408 (see Figure 4).
It is recognized
that conflicts can occur for complicated plan 408 designs and in cases where
override plan rules
401 are used (see Figure 10).
Referring to Figure 6, each of the rules 506 represents a unit of logic that
the adjudication
engine 24 executes during processing of the claim 20 (see Figure 1). A rule
specialist (not
shown) can create the logic of the policy 402 by writing one or more
corresponding rules 506 to
define the policy 402. The attributes associated with the elements of the
models 700,800,900
(see Figure 7 and 9) include the parameters that are required in the rules
506, which are
identified, and a template 600 containing the business logic and the required
parameters is
created for the group administrator (using the administrator module 410) to
populate. A range
for each parameter can also be defined. The group administrator populates the
template 600 with
their desired parameters, which include the Terms & Conditions 406. The
populated template
600 represents an instantiated policy 602.
For example, the Rules Specialist can writes a maximum policy 402 including
maximum
rules 506:
~If the (max type)'s accumulated maximum amount on (benefit value) for the
claimed
(max period) is greater than (max value), then (max_action) the line item.
CA 02508591 2005-05-27
~If the (max type)'s accumulated maximum on (benefit value) for the claimed
(max period) plus the total eligible amount of the claim is greater than (max
value),
then total eligible amount equals (max value) minus accumulated maximum
amount.
~If the (max type)'s accumulated maximum on (benefit value) for the claimed
(max period) plus the total eligible amount of the claim is equal to or less
than
(max value) then total eligible amount equals total eligible amount.
The Rules Specialist then creates a maximum template 600 from the policy 402
logic.
The Group Administrator then fills in the template 600 with their desired
parameters 406 to
populate the maximum template 600 representing the instantiated maximum policy
602:
~If the (patient)'s accumulated maximum on (orthodontics) for the claimed (one
calendar
year) is greater than ($2000), then (deny) the line item.
~If the (patient)'s accumulated maximum on (orthodontics) for the claimed (one
calendar
year) plus the total eligible amount of the claim is greater than ($2000),
then total
eligible amount equals ($2000) minus accumulated maximum.
~If the (patient)'s accumulated maximum on (orthodontics) for the claimed (one
calendar
year) plus the total eligible amount of the claim is equal to or less than
($2000) then
total eligible amount equals total eligible amount.
Referring to Figure 4, the agreement 404 can represent a contract between the
group (set
of people 12) and the payor 16 (see Figure 1) for insurance coverage. The
agreement 404
outlines the policies 402 applicable to the agreement 404 such as the
Adjudication Policy 502
(see Figure 5). The agreement 404 also identifies agreement items belonging to
the agreement
404, such as but not limited to claim types of health and dental. The
agreement item may specify
a benefit list (eg. Dental Benefit List 1 ) and any policies 402 that apply to
the agreement item,
such as fiscal, eligibility, or pricing policies 402. For example, it is
recognized that the fiscal
policy 402 can contain fiscal rules 506 such as but not limited to eligibility
of
people/services/products, maximums, deductibles, copay, and service/product
limits. The benefit
policy 402 can contain benefit rules 506 such as but not limited to rules
described by the health
disciple (e.g. dental can't fill a tooth that was previously pulled). The
pricing policy 402 can
contain pricing rules 506 such as but not limited to geography, time,
provider, and payment
arrangements. The terms & conditions 406 associated with the agreement 404 or
the agreement
items specify the parameters to these policies 406. Examples of the terms and
conditions 406
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CA 02508591 2005-05-27
include such as but not limited to what is covered, annual dollar maximum, and
prices according
to current health care fee guides. It is recognized that the agreement 404 and
associated policies
402 and conditions 406 represent the plan rules 401.
Referring to Figure 7, the people 12 of Figure 1 are represented as the
structured people
model 700, such as a hierarchical tree. The model 700 has an implicit
inheritance, such that
attributes associated with elements 712 of higher levels are automatically
associated with the
elements 712 of the lower levels, on a global basis. The model 700 can have
such as but not
limited to a payor level 702, a group level 704, a membership level 706, and a
person/individual
level 708. It is recognized that the levels can have sublevels, such as a
subgroup level 710. Each
of the levels has a number of elements 712, as specified in the plan 408 (see
Figure 4). The
model 700 is such that individual groups 704 are associated with certain
payors 702. Further,
individual memberships 706 are associated with certain groups 704 and
individual people 708
are associated with certain memberships 706. For example, attributes of the
plan 408 (see Figure
4) that belong to group 2 also belong to the persons 2,3,4,5,6, etc... under
the global attribute
assignment or hierarchy of the model 700. For further clarification, it is
recognized that some
attributes of the people level 708 would not be shared by other levels 702,
704, 706, due to the
upper level to lower level inheritance scheme of the model 700. It is
recognized that lower to
higher and other structured global inheritance schemes other than described
can be employed, if
desired.
Referring to Figure 8, it is recognized that the providers 14 of Figure 1
could be
represented as a structured provider model 800, such as a hierarchical tree.
The model 800 has
an implicit global inheritance, such that attributes associated with elements
812 of higher levels
are automatically associated with the elements 812 of the lower levels, on a
global basis.The
model 800 can have such as but not limited to a provider group level 702 and a
provider level
804. It is recognized that the levels can have sublevels. Each of the levels
has a number of
elements 812, as specified in the plan 408 (see Figure 4). The model 800 is
such that individual
providers 804 are associated with certain provider groups 802. For example,
attributes of the
plan 408 (see Figure 4) that belong to provider group 2 also belong to the
providers 1 and 2
under the global attribute assignment or hierarchy of the model 800. For
further clarification, it
CA 02508591 2005-05-27
is recognized that some attributes of the provider level 804 would not be
shared by other levels
802, due to the upper level to lower level inheritance scheme of the model
800. It is recognized
that lower to higher and other structured inheritance schemes other than
described can be
employed, if desired. Examples of Provider Groups 802 are such as but not
limited to: Locations,
PPOs, Chains, and Professional Associations. It is recognized that examples of
the providers
804 can be dentists, doctors, drug stores, etc...
Referring to Figure 9, it is recognized that the benefits 400 of Figure 4
could be
represented as the structured benefits model 900, such as a hierarchical tree.
The model 900 has
an implicit global inheritance, such that attributes associated with elements
912 of higher levels
are automatically associated with the elements 912 of the lower levels, on a
global basis. The
model 900 can have such as but not limited to a Benefit List level 902 and a
Benefit Item level
904. It is recognized that the levels can have sublevels. Each of the levels
has a number of
elements 912, as specified in the plan 408 (see Figure 4). The model 900 is
such that individual
benefit items 904 are associated with certain benefit lists 902. For example,
attributes of the plan
408 (see Figure 4) that belong to Benefit List A also belong to the Benefit
Items 1 and 2 under
the global attribute assignment or hierarchy of the model 900. For further
clarification, it is
recognized that some attributes of the level 904 would not be shared by other
levels 902, due to
the upper level to lower level inheritance scheme of the model 900. It is
recognized that lower to
higher and other structured inheritance schemes other than described can be
employed, if desired.
As noted above with reference to Figures 1 to 9, the rules 506 represent units
of logic that
the adjudication engine 24 executes. The plan 408 is made up of people models
700 and benefit
models 900 that contain global inheritance for attributes of the models 700,
900. It is recognized
that the model 800 could also be included as part of the plan 408, as desired.
The models 700,
800, 900 of the plan 408 are linked via policies 402 and agreements 404,
populated as a global
plan rule 401 to create a specific tailored plan 408, such as a company plan
for dental involving
company employees and dependents. The policies 402 of the plan rules 401 are a
collection of
the rules 506, and have modifiable parameters (terms & conditions 406) that
can be set by the
administrator. The agreements 404 can be part of the plan rules 401 and help
to link parties
(people 12/providers 14) to policies 402, their terms & conditions 406 and
benefit lists 400
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CA 02508591 2005-05-27
(where applicable). In the case where the plan 408 needs to be modified for
certain local benefits
400, providers 14, and/or people 12 of the plan 408, additional local plan
rules 401 can be
attached between the models 700, 800, 900 to override selected global
attributes. The addition of
local plan rules 401 provides for a flexible insurance plan which is a
combination of people 12 in
a first model 700 combined with benefits 400 of a second model 900, whereby
the combination
of the models 700,900 to create the plan is controlled by plan or
administration rules 401,
assigned both locally and globally. The models 700, 900 have inheritance of
attributes
associated with elements of the models 700,900 in a predetermined manner. The
interaction of
the models 700,900 and the administration rules 401 (local and global) helps
to provide for the
design of flexible insurance plans 408.
The administration rules 401 can comprise payment rules 506, enrolment rules
506, and
submission rules 506, for example, whereby tailored inheritance in the form of
overrides
provided (by application of the local administration rules 401) can be
enforced across the models
700,900 of the plan 408. Further, the administration rules 401 also permit the
override of global
attributes assigned by the hierarchical nature of the models 700,900.
Accordingly, the flexible
insurance plan system 409 (see Figure 4) can change rules to customize plans
408 or to tailor
administration of a selected element 712 within the people model 700 using
only the first and
second models 700, 900, rather than implementing separate tailored models
700,900 for the
selected element 712 (in addition to the two models 700, 900 used for the rest
of the elements
712) with attached fixed rule sets 506, as is standard practice in the
industry. Further, conflict
resolution is provided by using local priority setting of policies 402 within
the administration
rules 401 to affect the global order of execution specified in the policy
model 500.
In general:
Overrides
Overrides are modifications to the parameters of the policy(ies) 402 that can
be made by
a Claim Examiner (not shown) using the a Payor Claim Submission System (such
as the module
410) for a particular claim 20, subclaim 200 or line item 202. These overrides
are considered by
the Adjudication Engine 24 during the processing of the affected claim 20,
subclaim 200 or line
item 202. Potential example items that may be overridden include such as but
not limited to
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CA 02508591 2005-05-27
rules 506 associated with: Benefit Eligibility Policies; People and Provider
Eligibility Policies;
Pricing Policies; and Fiscal Policies.
Rule Inheritance and Conflict Resolution
Rules 506 can be placed at various points along the product 900, people 700,
or provider
800 hierarchies. Entities/elements lower in the hierarchy globally inherit
rules 506 from
entities/elements that are above them. Local administration rules 410 placed
on entities lower in
one hierarchy have more priority over global rules 410 and attributes above
them in the same
hierarchy, if the global and local rules conflict (i.e. override feature). In
the case where the item
appears in multiple hierarchies, each hierarchy is assigned a priority through
the policies 402 in
order to facilitate conflict resolution.
Policy/Rule Execution Order
The order in which rules 506 of the plan 408 are to be processed by the engine
24 can be
defined in such as but not limited to two ways:
Implicitly - The order may be globally inherent within the policy model 500
itself. If the
condition of the rule 506 within the policy 402 is dependent on the results of
another rule
506, then it is implied that the other rule 506 must execute first; and
2. Explicitly - Policies 402 can be assigned a local priority. This results in
a type of flow
between the policies 402 of the model 500.
Referring to Figure 10, an example of the people model 700 and the benefits
model 900
is shown, such that the plan 408 (see Figure 4) for Company A and Dental
coverage is created by
plan rule 401a. In this illustration, the people 700 of Group 1 (and all
associated lower levels)
for Company A get the dental model 900 having a maximum of $3000, with
complete exams and
limited exams on a frequency of one per 18 months. However, three additional
plan rules
401b,c,d have been implemented between the models 700, 900 to override the
global inheritance
of the models 700, 900, in order to create the plan 408 tailored to certain
individuals for specified
attributes of the plan rules 401 a,b,c, while leaving other attributes of the
plan 408 to be assigned
by the global inheritance of the models 700, 900. For example, plan rule 401b
overrides the plan
maximum and sets it to $5000 for Group N and Members 1 to N thereof. Plan rule
401c also sets
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CA 02508591 2005-05-27
the complete exam frequency at 1 per 24 months for Group N and all members
thereto. However,
it is noted that plan rule 401d sets Member N of Group N having complete exams
at one per
every 12 months. Hence, plan rule 401b overrode certain global inherence
attributes of plan rule
401 a, plan rule 401 c overrode other global inherence attributes of plan rule
401 a different from
plan rule 401 b, and plan rule 401 d overrode the override attributes of plan
rule 401 c.
Accordingly, member 1 of group N gets local attributes of the maximum of $5000
and the one
complete exam every 12 months along with all other non-overridden global
attributes assigned
by the plan rule 401a. Member N of group N gets local attributes of the
maximum of $5000 and
the one complete exam every 24 months along with all other non-overndden
global attributes
assigned by the plan rule 401 a. All other persons of the plan 408 for Group 1
remain unaffected
by the local override attributes of plan rules 401b,c,d.
Example of Rule Resolution Between Products
Referring to Figure 11, the benefit model 900 has a series of local
administration rules
401 attached and the policies 402 of the associated plans A,B have a priority
setting 930 on them
such that rules on plan B have greater priority than rules on plan A. This
priority setting 930 in
this case is a consequence of the attaching of the two local administration
rules 401 having
different co-insurance percentages. Accordingly, code X would be in conflict
(both 90% and
80%) if it was not for the priority setting 930. Accordingly, following the
logic of the global
inheritance and the locally imposed administration rule 401 inheritance and
priority 930, the
resulting conflict resolution is:
~ Code X of plan A and plan B both follow the 80% co-insurance;
~ Codes A & B are both subject to a frequency of 1 per 9 months with a maximum
of $5000;
and
~ Codes C & D both have a maximum of $2000 with the 80% co-insurance.
Example of Rule Resolution Between People
Referring to Figure 12, the people model 700 has a series of local
administration rules
401 attached and the policies 402 of the associated Subgroups 1 and 2 have a
priority setting 930
on them such that policies 402 on Subgroup 1 have greater priority than
policies 402 on
14
CA 02508591 2005-05-27
Subgroup 2. This priority setting 930 in this case is a consequence of the
attaching of the two
local administration rules 401 having different co-insurance percentages.
Accordingly, person 2
would be in conflict (both 100% and 80%) if it was not for the priority
setting 930. Accordingly,
following the logic of the global inheritance and the locally imposed
administration rule 401
inheritance and priority 930, the resulting conflict resolution is:
~ Person 1 and Person 2 follow the 100% co-insurance;
~ Person 3 follows the 80% co-insurance; and
~ Person 4 follows the 90% co-insurance.
It will be appreciated that variations of some elements are possible to adapt
the invention
for specific conditions or functions. The concepts of the present invention
can be further
extended to a variety of other applications that are clearly within the scope
of this invention.
Having thus described the present invention with respect to preferred
embodiments as
implemented, it will be apparent to those skilled in the art that many
modifications and
enhancements are possible to the present invention without departing from the
basic concepts as
described in the preferred embodiment of the present invention. Therefore,
what is intended to
be protected by way of letters patent should be limited only by the scope of
the following claims.
